CBT in the Real World

In the past few months I’ve seen several comments about how CBT is “constrained” by treatment protocols. Apparently, some practitioners have the impression that CBT is “cookbook” approach where the therapist takes a manualized treatment protocol and imposes it on the client without tailoring it to the client’s needs. They seem to think that if the client is depressed we march them through a 12-session protocol for depression, if they have OCD we march them through a 12-session protocol for OCD, etc. Is that how it really works?

It is Monday morning and a therapist looks at his schedule: “Let’s see … at nine I have a couple who haven’t been able to extricate themselves from an on-again, off-again relationship; then I have a young executive recovering from depression complicated by alcohol abuse and Paranoid Personality Disorder. Next I go to the Family Practice Center to see a client with somatic symptoms of stress, a young father obsessed with the thought of harming his child, and a family with chronic conflict among adolescent children. Later I return to my office to see a dentist with chronic social anxiety, an agoraphobic housewife, and a CPA troubled by anxiety, depression, and outbursts of anger.”

While the monologue above is imaginary, the caseload on that particular Monday was real and illustrates a major aspect of the practice of CBT. Specific treatment protocols have been develop and tested for specific disorders such as depression, phobias, OCD, substance abuse, and so on, with excellent results. However, the practicing therapists know that life is not that simple. Clients rarely present with a single problem for which there is a well-validated treatment protocol. More typically, clients enter treatment with multiple problems, with a variety of factors complicating therapy, or with problems for which empirically tested treatment approaches are not yet available. The clinician is then faced with the task of figuring out what to do.

When you read about the principles of CBT, it can seem fairly straightforward. Actually, the practice of CBT is often quite complex. Standardized treatment protocols are essential when one is trying to do well-controlled research but, by and large, they are not intended for routine clinical use. Ideally, CBT is tailored to the needs of the client based on an individualized understanding or the individual, his or her problems, and the interpersonal and cultural context. Empirically tested treatment protocols are useful in figuring out how to address the client’s problems effectively but in clinical practice it usually is necessary to apply CBT thoughtfully if one is to meet the client’s needs. For example:

Helga was a 25 year-old Czechoslovakian immigrant who was referred for therapy by her lawyer following her third conviction for shoplifting. She had a long history of episodes during which she would impulsively steal small items from department stores, often discarding them later. She was a generally law-abiding individual with strong religious values and professed an inability to control her impulse to steal. While she expressed a desire to stop stealing, she was reluctant to enter therapy because “I don’t believe in it” and because she doubted that it would be helpful. She accepted referral for therapy primarily because her lawyer thought that doing so might help her avoid a jail sentence.

In addition to the problems presented by Helga’s being an unwilling client and having a poor command of English, the therapist had no previous experience treating Kleptomania and was not aware of any reports of CBT having been used as a treatment for Kleptomania (this was a number of years ago). However, after a series of telephone calls revealed that there were no local therapists who were fluent in Czech and that the one local therapist known to be experienced in treating Kleptomania was unavailable, it was concluded that a trial of Cognitive Therapy was at least as promising as the other options open to Helga.

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The initial phase of therapy consisted of spending considerable time attempting to develop a collaborative relationship with Helga. The initial evaluation had not proven very helpful in understanding the stealing both because she described each episode as occurring spontaneously without any precipitant and because she was unable to describe any thoughts or feelings which preceded the stealing or coincided with it. Thus, the second stage of therapy consisted of a detailed assessment of the client’s episodes of stealing.

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Helga was asked to record thoughts and feelings associated with mild impulses to steal as they occurred as well as any actual episodes of stealing that might occur. Over the course of several weeks of self-monitoring, it gradually became clear that the impulse to steal arose at times when Helga was quite angry over situations unrelated to the stealing. The impulses were accompanied by thoughts about “getting even” and thoughts expressing the belief that others’ mistreatment of her justified the stealing. A close look at the situations which angered her and at the ways in which she handled anger revealed that she frequently felt abused and mistreated in fairly ordinary situations, directed her anger at “the system” rather than at the individual who she saw as mistreating her, believed that she was helpless to do anything about the mistreatment, and failed to make use of appropriate options for handling situations she was angry about. As she saw it (at times when she was angry) she was being mistreated by “the system” and was therefore justified in retaliating by stealing from department stores since they were another part of “the system”.

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Given this understanding of her impulsive stealing, it was possible to develop a treatment plan that focused on the key elements of her problem. This included working to improve her impulse control, working to get her to focus on the specific situations that elicited her anger rather than “the system” in general, helping her to recognize and challenge the cognitive distortions which amplified her anger over situations that others would find aggravating rather than infuriating, and helping her learn more adaptive ways to handle situations that angered her. Interventions included identifying and challenging the cognitions that blocked adaptive responses as well as improving her skills in assertion, clear communication, and effective problem-solving.

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Over the course of 20 sessions her impulse control improved, she became more effective in handling problem situations, and she reported that the impulse to steal had become less and less frequent and then vanished. While it was not possible to document conclusively that she was not stealing, both her lawyer and her probation officer were convinced that she had made sufficient progress to permit termination of therapy, and after termination she went for over two years without an arrest.

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It is with complex or atypical clients such as Helga that the need for a strategic approach to intervention is most obvious. In working with clients who have multiple problems or with clients who have personality disorders, no empirically validated treatment protocols are available and the therapist can easily feel overwhelmed and confused if he or she is does not approach the client systematically. If such clients were rare, it might make sense to reserve the strategic approach for clients who are clearly complex or with whom a “standard” approach proves ineffective. However, difficult clients are anything but rare and, in addition, a strategic approach to CBT is helpful with “easy” clients as well. With all clients, an individualized treatment approach provides the therapist with an opportunity to improve the effectiveness and efficiency of therapy.

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Therapists who have taught themselves CBT or who have only been trained to use structured CBT protocols may not know how to apply CBT flexibly and thoughtfully and may indeed find themselves “constrained” by protocols. This isn’t a limitation of CBT, it is an effect of having limited training in CBT. There are quite a few good books, workshops, and other training opportunities designed to help therapists learn a more sophisticated approach to CBT. I’m a particular fan of Clinical Applications of Cognitive Therapy (https://www.amazon.com/exec/obidos/ASIN/0306484625/behavioralheal02) and of the training that we offer at the Cleveland Center for Cognitive Therapy (http://www.behavioralhealthassoc.com/educationalPrograms).

James Pretzer, Ph.D. is the Director of the Cleveland Center for Cognitive Therapy and is Assistant Clinical Professor of Psychology in the Department of Psychiatry at the Case Western Reserve University School of Medicine. He received his Ph.D. in Clinical Psychology from Michigan State University and completed a post-doctoral fellowship at the Center for Cognitive Therapy at the University of Pennsylvania where he worked closely with Aaron T. Beck, M.D., David Burns, M.D., and other leading cognitive therapists.
Jim and his wife, Barbara Fleming, Ph.D., have been actively involved in applying Cognitive Therapy in areas such as the treatment of personality disorders and marital problems. They have also been providing advanced training in Cognitive Therapy for mental health professionals for over thirty years (see http://www.behavioralhealthassoc.com/educationalPrograms.php).
Jim is a co-author, with Art Freeman, Barbara Fleming, and Karen Simon, of Clinical Applications of Cognitive Therapy (second edition, 2004) and he is a co-author, with Aaron T. Beck and colleagues, of Cognitive Therapy of Personality Disorders (second edition, 2004). He has also authored and co-authored a number of papers and book chapters on a range of topics in Cognitive Therapy. Jim has presented his work at conventions of the Association for the Advancement of Behavior Therapy, the World Congress of Behavior Therapy, and the American Psychological Association, as well as in workshops locally, regionally, and internationally. His work has been translated and published in a number of languages including German, Japanese, and Swedish.

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